How Often Do Veterinarians Encounter Economic Limitations to Care?

Client financial limitations compromising patient care has been documented as the most common ethical dilemma encountered by small animal veterinarians (Batchelor and McKeegan 2012; Kipperman et al. 2018; Moses et al. 2018; Quain et al. 2021). In a study of US small animal veterinarians, 57% reported that economic limitations of clients adversely affected their ability to provide the quality of care they would like at least once or multiple times per day (Kipperman et al. 2017). A recent report found that 64% of veterinarians and veterinary technicians faced difficult decisions about client finances at least weekly (Quain et al. 2021). In another study of small animal veterinarians, euthanasia requests perceived to be based on lack of financial means occurred with a median frequency of once a month, and euthanasia requests where the respondent believed this decision was due to client unwillingness to pay for treatment, with a median frequency of a few times a year (Kipperman et al. 2018).

Consequences of Economic Limitations

Consequences of economic limitations for animals and veterinary professionals include a decrease in the number of visits to the veterinarian, delayed presentation to the veterinarian so the animal is seen when illness is more advanced, decline in quality of patient care, economic euthanasia, professional income limitations, and moral stress (see Chapter 22).

Veterinarians have the desire and capacity to heal their patients, and to have that capability be repeatedly denied because of economic limitations is inevitably disheartening; 77% of small animal veterinarians reported that the economic limitations of clients were either a moderate or primary contributor to their burnout (Kipperman et al. 2017). For caring practitioners, the moral stress incurred by economic constraints may have debilitating consequences such as career disenchantment and premature transition out of clinical practice, demoralization, or desensitization to the plight of patients and blaming clients as an adaptive mechanism.

From a client’s perspective, being denied access to the best care available for their animal over money may elicit feelings of guilt and a negative perception of the veterinary profession as placing economic considerations above patients. This can result in resentment toward the veterinarian and the profession (Sandoe et al. 2016). The reason most frequently cited among pet owners for leaving a practice was cost of care (Brown 2018).

Veterinarians in practice learn quickly that client complaints commonly relate to money. Frequent criticisms on websites that review hospitals include spending money on diagnostic testing when results are inconclusive or normal, or on treatments that are not successful. Veterinarians may feel the greatest pressure when clients “invest” in animals that die. Some clients will accuse the veterinarian of exploiting the patient for income, knowing the outcome would be poor. This can have a profoundly detrimental effect on a veterinarian’s willingness to recommend costly and risky procedures that may benefit patients.

In a recent study of small animal internal medicine specialists, the most common reason cited for client complaints was the cost of care and 43% considered changing their career because of complaints made against them (Bryce et al. 2019). Another study concluded that complaints about fees arose in the context of serious complications or patient deaths that the veterinarian had not predicted (Gordon et al. 2019). Multiple investigations have concluded that client complaints about cost of care are a common source of psychological stress for veterinarians (O’Connor 2019; Bryce et al. 2019).

Despite many advances in the veterinary profession in the past few decades, on the issue of economic limitations, little progress has been made. If no action is taken by the profession to change this, veterinarians are likely to hear the following statements from clients over the course of their careers:

“If you only cared enough, you would do the work without profit” (Bonvicini 2009).

“You’re a veterinarian; you’re supposed to love animals” (Bonvicini 2009).

“You’re going to let him die over $1000?”

Options for Addressing Economic Limitations

The majority of veterinarians report using the following methods to address economic limitations (Access to Veterinary Care Coalition and the Center for Applied Research and Evaluation 2018):

1. Offer a variety of treatment options.
   
2. Payment options such as installment plans.
   
3. Provide services for reduced fees or no charge.
   
4. Other financial resources such as pet health insurance and credit services.

The options most frequently offered by small animal veterinarians to clients with economic limitations included credit services (66% of practitioners), hospital-based payment plans (18%), acceptance of postdated checks (11%), and pro bono or discounted services (5%) (Kipperman et al. 2017). Most veterinarians in one study agreed that pet owners should be required to supply verification of income before receiving veterinary care at reduced fee or at no cost (Access to Veterinary Care Coalition and the Center for Applied Research and Evaluation 2018).

As of the end of 2020, almost 3.5 million pets in North America were insured (NAPHIA 2021). Based on a conservative estimate of 145 million companion animals in the United States (AVMA n.d.a), the prevalence of insurance is about 2%. A study substantiates this, as 76% of North American small animal veterinarians estimated that less than 5% of their clients had pet health insurance (Kipperman et al. 2017). By comparison, 58% of dogs and 36% of cats in the United Kingdom are insured (Statista 2019a and b) and in Sweden, 80% of dogs and 25% of cats are insured (Konkurrensverket 2018).

Effects of Client Awareness of Veterinary Care Costs and Pet Health Insurance on Patient Care

Before a recommendation can be made regarding what veterinarians should do to mitigate economic limitations, the potential benefits associated with improved client education regarding future veterinary care costs and pet health insurance must be known. In a report examining these issues, most small animal veterinarians felt that increased client awareness of potential future veterinary care costs would have a positive effect on financial stress and money-saving behavior of clients, the veterinary–client relationship, and professional stress and job satisfaction (Kipperman et al. 2017). Approximately three-quarters of practitioners believed an increase in client awareness of potential future veterinary care costs would have a positive effect on their ability to provide the medical care they feel is in the best interest of their patients.

Most small animal veterinarians also believe that increased adoption of pet health insurance would have a positive effect on financial stress for clients, the veterinary–client relationship, economic euthanasia, professional stress and job satisfaction, and their ability to provide the desired medical care for their patients (Kipperman et al. 2017). A recent study concluded that dog owners with pet health insurance spent significantly more money on veterinary visits (Williams et al. 2020).

Gastric Dilatation-Volvulus (GDV) is a life-threatening condition of older dogs. Diagnosis is inexpensive, and there is an 87% chance of recovery with surgery (Song et al. 2020), but emergency surgery and hospitalization can cost at least $5000. A retrospective study of dogs with GDV presenting to emergency clinics found that euthanasia decisions were primarily due to costs; only 10% of insured dogs were euthanized before surgery and noninsured dogs were seven times more likely to be euthanized (Boller et al. 2020). The authors concluded that pet health insurance is very successful in preventing preoperative euthanasia.

These studies suggest significant benefits to all parties involved in the practice of veterinary medicine from greater awareness among owners of the costs of veterinary care and pet health insurance.

Discussion of Veterinary Care Costs and Pet Health Insurance

Discussion of veterinary care costs is fundamental to patient care, client satisfaction, and practice success (Bonvicini 2009). Pet owners may be distrustful because of the tension they perceive between veterinary medicine as a healing profession and veterinary medicine as a business (Coe et al. 2007). Communicating about the costs of veterinary care with emotional clients in a manner that will be perceived as caring can be challenging and is a source of anxiety for many veterinary professionals (Coe et al. 2007). Morris (2012) concluded that veterinarians experience guilt regarding the costs of care and that “veterinarians often hate talking with clients about money.”

Results of a survey indicate that pet owners are generally not satisfied with the extent of discussions regarding costs provided by small animal veterinarians, and many stated that they received little information about pet health insurance from their veterinarian (Coe et al. 2007). Results of another study found that only 29% of companion animal veterinary visits included a discussion of actual costs (Coe et al. 2009). Moreover, costs were discussed in only 42% of visits in which diagnostic testing was recommended.

A recent investigation found that 67% and 71% of small animal veterinarians in the UK and Denmark, respectively, frequently or always discuss insurance with pet owners (Springer et al. 2021). By comparison, only 31% and 23% of Canadian and US small animal veterinarians discussed potential future veterinary care costs and pet health insurance, respectively, with over half of their clients (Kipperman et al. 2017). Reasons most frequently cited for not discussing these topics were lack of time and the belief that it would not change client behavior or financial preparation (Kipperman et al. 2017). Yet, most of these veterinarians believed that there should be an increase in efforts to improve client awareness and adoption of pet health insurance (Kipperman et al. 2017). In fact, a recent report concluded that providing pet owners with information about the costs of disease can increase their willingness to purchase pet insurance (Verteramo Chiu et al. 2021).

It is difficult to reconcile the documented benefits associated with improved client education regarding potential future veterinary care costs and pet health insurance with the small proportion of Canadian and US veterinarians who report that they routinely discuss these topics with their clients.

An Ethical Argument for Discussing Costs of Care with Clients

Neutering of small animal patients is customary in the United States, and virtually all general practitioners address this topic with the majority of their clients (Kipperman et al. 2017). Let’s pursue an ethical argument using neutering as a basis for routinely discussing costs of care with clients.

When animal welfare scientists make decisions regarding where to invest limited resources in addressing welfare concerns, four criteria are often considered (Smulders 2009):

1. The number of animals affected.
   
2. Duration of effect.
   
3. Is the problem reversible?
   
4. Impact on quality of life.

Hypothetically, if we did not routinely neuter dogs and cats, it is estimated that 20–60% of these animals would develop mammary cancer or become ill from pyometra (uterine infection) (Kustritz 2007; Howe 2015). These diseases typically affect older animals, which may be reversible with treatment or may be fatal. Based on the data presented in this chapter, it is reasonable to assume that at least 20% of all owned companion animals are subject to economic limitations to care. But unlike mammary cancer and pyometra, susceptibility to economic limitations is lifelong, affecting both young and old animals. Economic limitations to care may be reversible or may have fatal outcomes. A strong case can be made that these two issues have comparable welfare impacts on companion animals, but at this time the profession uniformly discusses neutering with clients and does not discuss economic preparation.

Who should conduct these conversations (see Script)? Veterinarians have a substantial influence on owner decisions with regard to their pet’s care. In one study, the veterinarian was identified as the most vital source of knowledge regarding pet care by 70% of pet owners (Sprinkle 2019), and another report found that 65% of consumers purchased pet health insurance because a veterinarian advised it (AVMA Veterinary Economics Division 2015). Potential drawbacks of addressing this issue are that clients may perceive the veterinarian as mercenary; clients may be dissatisfied with insurance company policies over which the practitioner has little control; or the client may not comply or prepare. Additionally, it is conceivable that a veterinarian’s awareness that a patient has insurance could lead to overuse of diagnostic tests or overtreatment (Springer et al. 2022).